Bladder Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Do you feel any kind of pain?Before UrinationAfter UrinationDo you feel any kind of burning?Before UrinationAfter UrinationDo you notice any blood in urine?YesNoDo you notice any pus in urine? YesNoDo you notice any abnormal discharge urine?YesNoDo you notice any kind of swelling around vulva?YesNoDo you experience any kind of Itching around vulva?YesNoAny of the complaints increase after intercourse?YesNoMostly my infections happen?Before menstruationAfter menstruationDo not applyHow often you have infections in past 6 months?Only once2-3 timesMore than 3 times How do you treat them usually?Drink fluidsTake antibioticsOthersWhat was your usual duration of infection without any treatment? 1-3 days3-7 daysMore than 7 daysSpecifyWhat was your usual duration of infection with any treatment? 1-3 days3-7 daysMore than 7 daysSpecifyAre you using any contraceptive devices?YesNoIf yes, since how long? Are you using any lubricating jelly?YesNoIf yes, since which one? specify Does your husband use condoms?YesNoIf yes, which one? Latex___ Rubber___Are you aVegetarianNon Vegetarian?Which types of food do you like? SpicyMildDo you have any Gastric Problem?YesNoDo you have constipation? YesNoAre you suffering from blood pressureYesNoIf so, whether it is? HighLowDo you suffer from heart problemYesNoDo you sleep wellYesNoHow many times you wake up to urinate during night? I don’t wake up.1-3 times4-6 times.More than 6 timesDo you exercise dailyYesNoYour partner has any sexual problem?YesNoHave you ever been treated in past?YesNoHomeopathicAllopathicAyurvedaothersIf so detailsHave you ever had kidney infection?YesNoHave you ever had kidney pain? YesNo What are your expectations from our treatment? I don’t expect good resultsI expect good results.I would be happy if I improve.I am confidentAre you willing to make changes to your life style or diet modifications? I can not change my lifestyle.I have tried nothing works for me.I am willing to change my lifestyle if needed.I am willing to do what ever is needed to get best results,WebsiteSubmit